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Posts Tagged eyelid surgery

Upper Blepharoplasty: Volume Enhancement via Skin Approach: Lowering the Upper

Jan 2

Posted by for healthy life in Cosmetic | No Comments

Lid Crease
Steven Faeien
Over the years, success of a particular surgical procedure, even aesthetic, has been measured mostly by perceived outcome and to some degree by the frequency of complications. Since the overwhelming majority of aesthetic periorbital ‘complications’ have occurred with lower blepharoplasty, most of the attention on newer and improved techniques has focused on the lower periorbita’”6 (see Chapters 14-19, Lower blepharoplasty).
As functional misadventures are a much less encountered occurrence after upper blepharoplasty, complacency with existing methods and perpetuation of ill-perceived solutions to rejuvenation of the upper periorbita prevail.7,8
With rare exception, the approach to upper blepharoplasty has not been particularly physiologic or individualized and the universal application of traditional remedies for upper periorbital rejuvenation has translated to mediocrity.7″”9 The prevailing perception has been that the appearance of the aged upper eyelid is primarily due to excessive skin, muscle, and fat often in conjunction with brow descent. Additionally, there is the confounding erroneous memory in many individuals of what their upper periorbita looked like in youth. Finally, there is the influence of the ‘famous and beautiful’ people on what patients may request for their eventual appearance despite their configuration in earlier years (Fig. 8-1) that may explain some of the historical aesthetic desires as well as changes in ideas and what is currently expected after surgery.
Steven Fagien
The consultation
As with all surgical approaches to rejuvenation, we must take into account what are the actual changes that occur in the upper periorbita and whether the existing methods consider these occurrences for a wide variety of indi¬vidual presentations (Fig. 8-2). Do these techniques result in a rejuvenative appearance or simply achieve a ’cause and effect’ outcome whereby an altered appearance replaces youth? (Fig. 8-3). And, ultimately, what surgical procedures are some patients willing to undergo and what do they expect from surgery?

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Lacrimal system

Nov 24

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Under normal circumstances there is a constant pro­duction of a tear film for corneal protection. The entire volume of this tear production by basic secretors evaporates from the surface of the cornea. Three sets of glands comprise the basic secretors. The conjuncti­val, tarsal, and limbal mucin-secreting goblet cells are responsible for producing a mucoprotein layer that forms the innermost layer of the precorneal tear film. This layer allows the overlying layers to spread more uniformly over the cornea. The second group of basic secretors consists of accessory lacrimal glands lying within the subconjunctival tissues. They are responsi­ble for producing an intermediate aqueous layer. The outermost layer of the precorneal tear film is produced by the Meibomian glands located within the tarsal plate, and the glands of Zeis and Moll at the root of the eyelashes. This layer stabilizes the film and helps reduce evaporation.

The main lacrimal gland is a reflex secretor, which respond to sudden changes in physical and emotional environment. The lacrimal gland is divided into an orbital and palpebral lobe by the lateral horn of the levator (Fig. 5-10). The larger orbital lobe is prone to prolapse against the overlying septum orbitale and on occasion in aesthetic blepharoplasty, a ptotic lacrimal gland produces a localized lid fullness requiring a simple rcsuspension. Tears from the orbital lobe pass through the palpebral lobe, which in turn empties into the superolateral conjunctival fornix via six to twelve tear ductules. Tears then pass from this lateral cul-de-sac to sweep across the cornea and empty into the lacrimal drainage system.

The excretory portion of the lacrimal system con­sists of a lacrimal lake, puncta, canaliculi, sac, and nasolacrimal duct. Tears pass from the lacrimal lake to the puncta into the ampullae and canaliculi. The upper and lower puncta are 5—7 mm lateral to the medial canthal angle, and the lower puncta is often lateral to the upper. The canaliculi are about 10 mm long (the initial 2 mm run in a vertical direction and the remainder horizontally) and join to form a single duct prior to entering the sac. The lacrimal sac extends inferiorly for approximately 10 mm and gives rise to the nasolacrimal, duct, which consists of an interosse­ous portion and a meatal portion. The duct opens just below the anterior end of the inferior nasal turbinate (Fig. 5-11). Traction on the deep portions of the orbi­cularis that attach to the surface of the sac creates a relative negative pressure that draws tears through the canaliculi into the sac. Relaxation of the orbicularis oculi allows the lacrimal sac to collapse, and the tears traverse the nasolacrimal duct to the nose.19

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Eyelid retractors

Nov 23

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The upper eyelid is responsible for 90% of eyelid opening. This action is mediated by the levator palpe-brae superioris and Miiller’s muscle. The levator pal-pebrae originates from the lesser wing of the sphenoid and extends anteriorly along the superior orbit. At 15-20 mm above the tarsal plate, the levator forms a condensation of fascia known as the superior transverse or Whitnall’s ligament (Figs 5-2 & 5-10). It extends from the lacrimal gland fossa laterally to the trochlea medially and is thought to act as a fulcrum to translate a horizontal into a vertical vector. It also has a suspensory role in the orbit and may function as a check ligament for the levator muscle to limit its excursion. Anterior to Whitnall’s ligament, the levator divides into an anterior aponeurotic layer and a poste­rior muscular layer. The aponeurosis passes over the tarsal plate to attach to the lower 7-8 mm of its ante­rior surface. It also sends fibers through orbicularis to the skin in the pretarsal zone. The attachment of the levator to the skin in this region determines the height and quality of the superior tarsal crease and therefore also impacts on the shape of the supratarsal fold.

The anterior prolongation of the lateral edge of the levator aponeurosis forms a lateral horn which divides the lacrimal gland into the palpebral and orbital lobes and contributes to the lateral canthal retinaculum. A medial horn inserts into the lacrimal crest as part of the medial canthal mechanism. The total length of the levator is approximately 40-45 mm, with a 10-15 mm aponeurotic extension and a total excursion of 10—15 mm. Posteriorly Miiller’s muscle attaches 10 mm away from its origin to the upper border of the tarsal plate. Miiller’s muscle consists of smooth muscle under sympathetic control. It is normally responsible for 2—3 mm of lid lift; however, with sympathetic stimula­tion an additional 1-2 mm of lift above baseline is possible. When sympathetic tone is lost in Horner’s syndrome, 2—3 mm of ptosis may be seen. In contrast to Miiller’s muscle, the levator is a striated muscle innervated by the oculomotor nerve.

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Tarsus and septum orbitale

Nov 21

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The tarsal plates are crescentic-shaped, dense conden­sations of connective tissue that maintain the structural integrity of the eyelids while accommodating the contour of the globe. The upper tarsus is approxi­mately 29 mm long and extends from the lateral com­missure to the punctum medially. It is 10 mm wide in the central eyelid, narrowing medially and laterally. The lower tarsus is a similar length to that of the upper but is only 4—5 mm wide at its center. The septum orbitale, or orbital septum, consists of a thin fibroelas-tic membrane of varying consistency that is notably non-distensible adjacent to the inferolateral orbital rim. It extends from the bony margin towards the tarsus and represents the continuation of the orbital periosteum. At the junction where the periosteum and septum fuse along the orbital rim is a dense white fibrous band termed the arcus marginalis (Fig. 5-8). The arcus marginalis is clearly evident inferomedially where the rim has a sharp edge, whereas it is less defined on the rounded inferolateral rim.

In the upper eyelid, the septum attaches to the levator aponeurosis, generally 2—5 mm above the supe­rior edge of the tarsal plate.lj However, this septal-levator attachment can vary from the level of the superior tarsal border to almost 10 mm above. Below this level there is a blending of the connective tissue lamellae from both the septum and the levator aponeu­rosis called the prctarsal extension of the levator or the conjoined fascia.14 This fascia continues inferiorly to attach to the lower third of the anterior surface of the

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Lateral canthus

Nov 21

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Despite varied anatomical descriptions and nomencla­ture, the lateral canthus should be considered in terms of a deep skeletal attachment via the lateral canthal tendon and a superficial fibrous attachment via the lateral canthal raphe and lateral orbital thickening. The deep attachment serves to stabilize the tarsal plates whereas the superficial attachment functions to stabilize the orbicularis over the orbital rim.6

The lateral canthal tendon is less well defined than the medial side and has less orbicularis muscle connec­tion. It takes the form of a Y-shaped fibrous condensa­tion measuring 6 mm in transverse length and up to 10 mm in vertical height. It extends from the upper and lower tarsal plates and is reinforced by significant attachments from the lateral horn of the levator apo­neurosis and the check ligament of the lateral rectus muscle as well as from Lockwood’s ligament. This confluence of structures (the lateral retinaculum) attaches to the lateral orbital wall at Whitnall’s tuber­cle, which is located just inside the orbital rim and approximately 10 mm below the zygomaticofrontal suture.9 Whitnall’s (superior transverse) ligament is part of the levator aponeurosis and is not part of the lateral canthus.

Superficially, the preseptal orbicularis fibers of the upper and lower lid interdigitate to form the lateral canthal raphe. The raphe, although often referred to in eyelid texts, has not been clearly described and is diffi­cult to identify as a discrete anatomical structure. It is connected on its deep surface to the underlying septum orbitale and merges laterally with a significant conflu­ence of fibrous tissue known as the lateral orbital thick­ening1 (Fig. 5-7). This thickening is a condensation of fascia passing over the orbital rim, lateral and superficial to the lateral canthal tendon. It has also been termed the ’superficial leaf of the lateral canthal tendon’10 and the ‘precanthal web’.” It is a triangular fibrous adhesion connecting the orbicularis fascia on the undcr-surface of the muscle to the underlying deep fascia, which in this region is made up of thickened lateral orbital rim peri­osteum and adjacent deep temporal fascia. The lateral orbital thickening is continuous with the orbicularis retaining ligament inferomedially and must be released surgically if a canthoplasty is to be effective.

The lateral canthus is positioned approximately 2 mm higher than the medial canthus. Despite previous assumptions, this is the same for both sexes and does not change with increasing age.12 Inherent variations of the intercanthal angle do, however, have a signifi­cant impact on facial aesthetics in normal people and descent of the lateral commissure secondarily to lateral canthal tendon laxity produces an apparent change in the lateral canthus position, which predisposes to a premature aging appearance.

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Eyelid support

Nov 20

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The complexity of eyelid anatomy reflects the compet­ing functional demands of providing support for the lid margins while allowing mobility of the lids. Primary eyelid support is provided through the bony attachment of the canthi with a secondary level of support from the orbicularis muscle and its fascial attachments.

The medial canthus is medial to the globe with a rigid fixation to the orbital wall. By contrast, the lateral commissure overlies the lateral part of the globe and is mobile, having up to 6 mm of vertical movement and 2 mm of lateral movement.6 These anatomical landmarks are determined by the medial and lateral palpebral ligaments, which provide the ligamentous support for the tarsal plates. The palpebral ligaments are commonly referred to as the medial and lateral canthal tendons on account of the pretarsal orbicularis fibers that contribute to their superficial surfaces. In addition, the orbicularis muscle and more particularly the fascia on its deep surface forms a continuous fibrous network of support through the orbicularis attachment to the tarsal plates and canthal tendons, and to the lateral orbital rim via the firm fibrous attachment provided by the orbicularis retaining ligament and the lateral orbital thickening.

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